Active Internal Rotation Research Articles

Variability in physical therapy protocols following total shoulder arthroplasty.

Physical therapy (PT) plays an important role in the recovery of function following anatomic total shoulder arthroplasty (aTSA). While several PT protocols have been published for these patients, there is no standardized protocol for aTSA rehabilitation. This lack of standardization may lead to confusion between patients and physicians, possibly resulting in suboptimal outcomes. This study examines how PT protocols provided by academic orthopedic surgery programs vary regarding therapeutic goals and activities following aTSA. PT protocols for aTSA available online from the Accreditation Council for Graduate Medical Education accredited orthopedic surgery programs were included for review. Each protocol was analyzed to evaluate it for differences in recommendation of length of immobilization, range of motion (ROM) goals, start time for and progression of therapeutic exercises, and timing for return to functional activity. Of 175 accredited programs, 25 (14.2%) had protocols publicly available, programs (92%) recommended sling immobilization outside of therapy for an average of 4.4±2.0 weeks. Most protocols gave recommendations on starting active forward flexion (24 protocols, range 1-7 weeks), external rotation (22 protocols, range 1-7 weeks), and internal rotation (18 protocols, range 4-7 weeks). Full passive ROM was recommended at 10.8±5.7 weeks, and active ROM was 13.3±3.9 weeks, on average. ROM goals were inconsistent among protocols, with significant variations in recommended ROM and resistance exercise start times. Only 13 protocols (52%) gave recommendations on resuming recreational activities (mean, 17.4±4.4 weeks). Publicly available PT protocols for aTSA rehabilitation are highly variable. Level of evidence: IV.

The long-term results of shoulder hemiarthroplasty in irreducible four-part fracture-dislocation of the proximal humerus without rotator cuff tear arthropathy.

Although there are concerns about nonunion of the greater tuberosity or shoulder weakness, hemishoulder arthroplasty (HSA) is a viable treatment option for irreducible four-part proximal humerus fractures-dislocation without rotator cuff tear arthropathy. This study aims to analyze the long-term radiological and functional outcomes of HSA. This study enrolled 36 patients who underwent HSA due to irreducible four-part proximal humerus fracture-dislocation without rotator cuff tear arthropathy between March 2005 and May 2020. The exclusion group included 10 reverse total shoulder arthroplasty patients. The mean age and mean follow-up period were 68.6years old and 48.6months, respectively. Radiological assessments, such as vertical and horizontal greater tuberosity position, greater tuberosity healing, and implant position, were evaluated. Clinically, American Shoulder and Elbow Surgeons Score (ASES), Constant-Murley Score (CMS), and range of motion were evaluated. The greater tuberosity union rate was 55.6% (n = 20), with 44.4% (n = 16) experiencing nonunion, malunion, and bone resorption. The mean vertical and horizontal greater tuberosity positions showed significant difference at last follow-up compared to immediate postoperation. The retroversion of the implant was 23.8 ± 4.61°, and the acromio-humeral interval was 7.6 ± 1.34mm. The mean last follow-up ASES and CMS were 39.5 ± 4.03 and 55.4 ± 10.41, respectively. The mean active forward flexion, abduction, internal rotation, and external rotation were 100.9 ± 15.04°, 92.5 ± 14.47°, 44.2 ± 12.83°, and 42.5 ± 15.32°, respectively. In long-term follow-up, the greater tuberosity was superiorly migrated and externally rotated. Active forward flexion and abduction in the last follow-up were significantly limited. However, in terms of pain relief, a satisfactory result was seen.

Midterm outcomes of autologous bridging of rotator cuff tears with an autologous tendon patch (TEAR patch)

Large and massive rotator cuff tears and tears after failed surgical repair are a challenging clinical problem with different treatment options. The purpose of the study was to evaluate the mid-term outcomes following rotator cuff repair (RCR) with autologous hamstring tendon graft bridging (TEAR patch) with the hypothesis, that outcomes would be reasonable and complication rates low. This is a retrospective case series study of patients who underwent open RCR using a TEAR patch from June, 2015 to March, 2019. evidence of cuff tear arthropathy, advanced fatty infiltration, moderate to severe arthropathy and workers compensation board or litigation involved. Clinical outcome measures: Constant score (CS), Disabilities of Arm, Shoulder and Hand score (DASH), Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), range of motion (ROM) and manual muscle test (MMT) for forward elevation, abduction, external and internal rotation, patient satisfaction, willingness to do the operation again. Radiographic outcome measures: MRI, ultrasound and radiographs: Graft integrity and acromiohumeral distance (AHD). 44 patients were followed (89%) for ≥ 2 years (45 shoulders, mean age 60.3 years (48-76), mean follow-up 4.3 years (2-6)). All clinical outcome measures (CS, DASH, SST, SSV, ROM, and MMT) demonstrated significant improvement except active external and internal rotation. At 2 years follow-up, the mean patient satisfaction was high (12.2 out of 15 points) and 33 of 38 patients (73.3%) would do the operation again. A perfect graft integration was observed in n=30 (66.7%) a small gap in n=7 (15.6%), a retear in n=3 (7%) and a complete failure of the tendon patch in n=5 (11%) patients. Graft integrity was strongly correlated with the postoperative AHD (r=0.599 , p=0.001 ) and the gain in AHD (r=0.599 , p=0.001) but not with ROM or PROM's or patient satisfaction. Four patients required revision surgeries (three due to deep infection and one for poor function and pain). Mid-term clinical and radiographic outcomes following RCR with graft bridging using a TEAR patch were reasonable. The procedure resulted in improved shoulder function and a high level of patient satisfaction. The revision rate is acceptable in view of the specific patient group and treatment alternatives. The described technique of the TEAR patch can be a valuable alternative to existing methods and a novel autograft source for rotator cuff surgeries that need bridging of a tendon defect.

Mini-Open Fascia Lata Interposition Graft Results In Superior 2-Year Clinical Outcomes When Compared to Arthroscopic Partial Repair for Irreparable Rotator Cuff Tear: A Single-Blind Randomized Controlled Trial

To evaluate and compare the results of surgical treatment for irreparable rotator cuff tear (IRCT) by the mini-open interposition procedure using fascia lata autograft against outcomes of the arthroscopic partial repair technique. An interventional, prospective, controlled, randomized, single-blinded study involving 2 study groups was conducted. The graft group (n= 20) underwent the mini-open interposition procedure using fascia lata autograft. The control group (n= 22) underwent arthroscopic partial repair. Patients were evaluated using the University of California Los Angeles (UCLA) Shoulder scale, the American Shoulder and Elbow Surgeons (ASES) score, the Constant-Murley (Constant) score, the visual analogue scale (VAS) pain score, active range of motion, frontal flexion strength, retear rates evaluated by magnetic resonance imaging analysis, occurrence of complications, and the minimal clinically important difference (MCID). The graft group had better UCLA (31.5 vs 28.18, P= .035) (100% exceeded the MCID for the graft group and 95% for the control group), ASES (88.62 vs 77.06, P= .016) (100% exceeded the MCID for both groups), Constant (78.85 vs 61.68, P < .001), and VAS (0.95 vs 2.59, P= .01) scores at the 24-month follow-up. For active forward elevation range, both groups showed no statistically significant differences (168.5 vs 164.54, P= .538). The results for active external and internal rotation were better in the graft group (60.25 vs 40, and 9.1 vs 6.9, P < .001), as was frontal flexion strength (4.24 vs 2.67, P= .005). The graft group also had lower retear rates (15% vs 45.5%, P= .033). No complications were reported. Outcomes of surgeries for IRCT by the mini-open interposition procedure using fascia lata autograft and by the arthroscopic partial repair technique showed good results in both groups over time and exceeded the MCID. However, most comparative outcomes between groups showed better results for the interposition procedure. Level I, randomized controlled trial.

Clinical and Radiological Outcomes in Lateralized versus Non-lateralized and Distalized Glenospheres in Reverse Total Shoulder Arthroplasty: A Randomized Control Trial.

Lateralization in reverse total shoulder arthroplasty (RTSA) has been used to theoretically offer the potential benefits of reduced scapular notching rates and improved stability and range of motion (ROM), particularly external rotation. The aim of this study was to compare ROM, clinical and radiographic outcomes between patients who underwent RTSA with a lateralized versus a non-lateralized and distalized glenosphere. A single surgeon randomized control trial was conducted comparing 27 patients with a lateralized glenosphere and 26 patients with a non-lateralized and distalized glenosphere. 66 patients were enrolled, two patients died prior to two-year follow-up, four patients withdrew from the study and seven patients were lost to follow-up. All patients in the lateralized group received 6 mm of lateralization through the glenosphere. Participants represented a population presenting to an orthopedics sports medicine clinic with any indication for RTSA including revision arthroplasty. Patients completed preoperative and routine postoperative functional outcome measures 3, 6, 12, and a minimum of 24 months postoperatively including American Shoulder and Elbow Surgeons (ASES), Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity (PROMIS PF UE) and Activities of Daily Living Requiring Active External and Internal Rotation (ADLEIR) assessments. Patients were also evaluated with ROM and radiographic measurements. The primary outcome of interest in this study was ROM, particularly external rotation. At two-year follow-up, both groups had significant improvement in their ASES, PROMIS PF UE and ADLEIR scores with no significant difference observed between groups. There were no statistically significant differences in incidence of scapular notching or acromial stress fractures. ROM in both groups improved significantly at their two-year assessment with the only exception to this being external rotation at 90° of abduction in the non-lateralized and distalized group (39° ± 31° versus 48° ± 24°, p=0.379). Regardless of glenosphere lateralization status, patients in both groups had significant improvement in functional outcome scores and ROM and there were no significant differences observed between groups at two-year follow-up. Longer follow-up is needed to determine the effect of implant design on late complications, long-term outcomes and implant retention.

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative rotational stiffness and an intact rotator cuff: a case control study.

Reverse total shoulder arthroplasty (rTSA) has begun to challenge the place of anatomic total shoulder arthroplasty (aTSA) as a primary procedure for certain indications. One purported benefit of aTSA is improved postoperative range of motion (ROM) compared to rTSA especially in internal rotation; however, it is unclear whether aTSA can provide patients with significant preoperative stiffness superior ROM compared to rTSA. Our purpose was to compare clinical outcomes of aTSA and rTSA performed in stiff vs. non-stiff shoulders for rotator cuff intact (RCI) glenohumeral osteoarthritis (GHOA). A retrospective review of an international shoulder arthroplasty database identified 1608 aTSAs and 600 rTSAs performed for RCI GHOA with minimum 2-year follow-up. Defining preoperative stiffness as ≤ 0° of passive external rotation (ER), we matched: (1) stiff aTSAs (n=257) 1:3 to non-stiff aTSAs, (2) stiff rTSAs (n=87) 1:3 to non-stiff rTSAs, and (3) stiff rTSAs (n=87) 1:1 to stiff aTSAs. We compared ROM, outcome scores, and the rate of complications and revision surgery at latest follow-up. Despite stiff aTSAs having poorer preoperative ROM and functional outcome scores for all measures assessed (P<.001 for all), only poorer postoperative active abduction (113±27° vs. 128±35°; P<.001), active ER (39±18° vs. 50±20°; P<.001), and passive ER (45±17° vs. 56±18°; P<.001) persisted postoperatively compared to the non-stiff cohort. Similarly, stiff rTSAs had poorer preoperative ROM and functional outcome scores for all measures assessed compared to non-stiff rTSAs (P≤.044), but only poorer active abduction (108±24° vs. 128±29°, P<.001), active ER (28±17° vs. 42±17°, P<.001), and passive ER (36±15° vs. 48±17°, P<.001) persisted. When comparing stiff rTSAs to matched stiff aTSAs, no significant differences in preoperative ROM or functional outcome scores were found. However, stiff aTSAs had greater postoperative active internal rotation score (4.8±1.5 vs. 4.2±1.7, P=.022), active ER (40±19° vs. 28±17°, P<.001), and passive ER (46±18° vs. 36±15°, P=.001). Postoperative outcome scores were similar across all matched cohort comparisons despite motion differences. The rate of complications and need for revision surgery did not differ between any group comparisons. Patients with RCI GHOA who have preoperative rotational stiffness have poorer postoperative ROM compared with non-stiff patients following both aTSA and rTSA, but similar functional outcome scores. Notably, preoperative limitations in passive ER do not appear to be a limitation to utilizing aTSA. Indeed, patients with limited preoperative ER treated with aTSA had greater postoperative internal rotation and ER compared to those treated with rTSA.

Factors that affect external rotation following reverse shoulder arthroplasty: a retrospective multi-centre study on 501 shoulders.

The purpose of this multi-centre study was to assess external rotation in a large cohort following reverse shoulder arthroplasty (RSA) at a minimum follow-up of 2years, and identify factors that influence postoperative and/or net-improvement of external rotation. The authors retrospectively reviewed records of 743 RSAs performed between January 2015 and August 2017 by 16 surgeons that participated in a large national society symposium; 193 (25.7%) were lost to follow-up, 16 (2.1%) died, and 33 (4.4%) were revised with implant exchange, which left 501 available for assessment at 2.0-5.5years. Pre- and post-operative active forward elevation, active external rotation (ER1), active internal rotation (IR1) and constant score (CS) were collected. Regression analyses were performed to determine associations of patient demographics, surgical and implant parameters, rotator cuff muscles status and radiographic angles with ER1. Multivariable analyses revealed postoperative ER1 decreased with age (β, - 0.35), increased with lateralisation shoulder angle (LSA) (β, 0.26), and was better in shoulders operated by the antero-superior (AS) approach (β, 11.41), but worse in shoulders with absent/atrophic teres minor muscles (β, - 10.06). Net-improvement of ER1 increased with LSA (β, 0.39), was better with inlay stems (β, 8.33) and BIO RSA (β, 6.22), but worse in shoulders operated for primary OA with rotator cuff (RC) tears (β, - 16.26), for secondary OA due to RC tears (β, - 16.06), or for mRCT (β, - 18.96). This large multi-centre study revealed that, at a minimum of 2years following RSA, ER1 improved by 16.1°. Postoperative ER1 was better in shoulders which had normal or hypertrophic teres minor muscles, were operated by the AS approach, or with greater LSA. Net-improvement of ER1 was better in shoulders with inlay stems, with BIO RSA, or with greater LSA, but worse in shoulders with rotator cuff deficiency. IV.

Concomitant latissimus dorsi tendon transfer during reverse total shoulder arthroplasty does not improve active external rotation or clinical outcomes in patients with external rotation deficit.

To assess the role of latissimus dorsi tendon transfer (LDT) concomitant with reverse total shoulder arthroplasty in patients with external rotation (ER) deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis. Patients with a positive external lag sign and <10° of active external rotation (aER) treated with reverse shoulder arthroplasty at a single institution with a minimum 12-month follow-up were retrospectively identified from a prospective database. Basic demographic information along with preoperative and postoperative range of motion (ROM) measures, American Shoulder and Elbow Surgeons score (ASES), Visual Analog Scale (VAS) pain, and Subjective Shoulder Value scores were obtained. Statistical analysis was performed to compare ROM and functional outcomes between patients who underwent concomitant LDT and those with no transfer (NT). The LDT (n=31) and NT (n=33) groups had similar age, sex distributions, and follow-up length average (24 vs. 30months). No differences were found between groups at baseline, final follow-up, or magnitude of change for ASES, VAS pain, and Subjective Shoulder Value scores. Baseline ROM measures were similar, except for the LDT group having slightly less aER (-8° vs. 0°; P=.004). In addition, all postoperative ROM measures including aER were similar, except for a slight improvement in active internal rotation in the NT group. The majority of patients were satisfied with their outcome (LDT 84% (n=26); NT 87% (n=27); P=.72). Patients with ER deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis undergoing reverse total shoulder arthroplasty do not have significantly improved ER or patient-reported outcome measures with LDT.

Latissimus Dorsi and Teres major tendon transfer increases internal rotation torque following lateralized reverse shoulder arthroplasty with subscapularis insufficiency.

Limitation of active Internal Rotation (IR) following Reverse Shoulder Arthroplasty (RSA) in patients with massive Rotator Cuff Tears (mRCTs) with subscapularis insufficiency remains a challenge. Recently, RSA with Latissimus dorsi and Teres major (LDTM) transfer in patients with limited active IR has been demonstrated as a reliable treatment option. The purpose of this study was to biomechanically compare the IR torque following LDTM transfer with RSA in mRCT with subscapularis insufficiency to RSA without tendon transfer. Eight cadaveric shoulders were tested (mean age: 64.5 ± 1.9years) using a custom shoulder testing system that permits loading conditions of mRCT with subscapularis insufficiency. Two conditions were tested and compared. The first condition was RSA alone and the second condition was RSA with LDTM transfer. RSA with a medialized glenoid and lateralized humerus design was used for all specimens. The specimens were tested at 0°, 20° and 40° abduction at three different muscle loads: baseline, double, and triple, while the Teres minor and deltoid loads were kept constant. IR torque was measured with a torque wrench at 0°, 20°, and 40° abduction and 60° and 45° IR positions. Force required for anterior dislocation was measured at 20° abduction and 10° IR position. RSA with LDTM transfer had significantly higher IR torque at all abductions and muscle loading compared with RSA without transfer (average at all positions; RSA without transfer: 0.80 ± 0.02 Nm, LDTM transfer for all loads: 1.43 ± 0.10 Nm). RSA with LDTM transfer (91.4 ± 3.9 N) needed higher force for anterior dislocation compared to RSA alone (89.4 ± 4.1 N), but there was no significant difference. LDTM transfer with RSA increases IR torque compared to RSA without tendon transfer in a cadaveric model. LDTM transfer with RSA may be a reliable treatment option for patients with mRCT and subscapularis insufficiency who are expected to have limited active IR following RSA.

THE INFLUENCE OF MOBILIZATION AND ISCHEMIC COMPRESSION ON PAIN AND DISABILITY IN ADHESIVE CAPSULITIS AND MYOFASCIAL PAIN SYNDROME

The purpose of the study: to investigate the effect of end-range mobilization and ischemic compression on pain and disability scores among patients with adhesive capsulitis of the shoulder joint and myofascial pain syndrome in the thoracic region.&#x0D; Materials and methods. Goniometry of the shoulder joint, assessment of pain at the end points of the range of motion and trigger points (when applying a pressure of 2.5 kg×cm-2), as well as the Shoulder Pain and Disability Index questionnaire were used before the intervention and after physical therapy.&#x0D; Physical therapy began after an examination and consultation with an orthopedic traumatologist. The majority of patients received 15 planned procedures of end-range mobilization performed by a physical therapist within 3 weeks, only two patients received 14 and 16 procedures. Mobilization from I to V degrees of intensity according to the Maitland classification was used. The patient performed ischemic compression independently after instruction (determination of the localization of trigger points, formation of their map, training in exposure techniques). Compression was performed with an average level of pain or more than average; duration of 30 seconds for each point.&#x0D; Results. The proportion of male patients was 20.8%. In the examined group of patients, the values of Me (25%; 75%) for age were 53.5 (48.25; 58.5) years, and for the duration of symptoms 4 (2; 5.5) months. Localization of adhesive capsulitis on the right side was observed in 9 patients (37.5%), and on the dominant upper limb in 8 (33.3%) patients. In five patients, the lesion was on the dominant right limb. The evaluation of the transfer of end-range mobilization procedures at the end of the first, sixth, eleventh and last procedure established that the maximum pain on a 10-point scale during mobilization was, respectively: 10 (9; 10) points, 8 (7.25; 9) points, 7 (5 ; 8) points and 4 (3; 5) points. In the course of physical therapy, the indicators of amplitudes of movements and pain at maximum amplitude, as well as at trigger points, improved statistically. The median value for active abduction increased by 74.5° and for active flexion increased by 116.5°. The median value for active internal rotation increased by 77.5°, and for active external rotation, flexion increased by 75°. The median value of pain when reaching the maximum amplitude of active abduction decreased by 6 points, and for active flexion, internal and external rotation, the median dynamics indicator was similar. It should be noted that the pain index at the trigeminal point at the first assessment was 9 (9; 9) points, and at the final assessment it statistically improved and was 4 (3; 4) points (Z = -4.340; p&lt;0.001). All items of the Shoulder Pain and Disability Index questionnaire improved statistically, leading to improvements in domain values and the index itself. Іndicators Me (25%; 75%) of the pain domain decreased from 93 (63; 100) points to 16 (6.5; 20) points (Z = -4.287; p&lt;0.001), and the disability domain from 83.8 (56.9; 91.6) points to 5.6 (3.8; 10.9) points (Z = -4.286; p&lt;0.001). Тhe median indicator of the pain domain decreased by 77 points, and the disability domain by 78.2 points. The index decreased from 88.7 (54.1; 94.4) points to 10.5 (4.2; 15.4) points. (Z = -4.286; p&lt;0.001).&#x0D; Conclusions. The use of a combination of end-range mobilization and ischemic compression was effective in reducing the index of shoulder pain and disability among the examined patients.

Biomechanical comparison of combined latissimus dorsi and teres major tendon transfer vs. latissimus dorsi tendon transfer in shoulders with irreparable anterosuperior rotator cuff tears.

Irreparable anterosuperior rotator cuff tears (IASRCTs) can result in a gradual loss of active elevation and internal rotation, superior and anterior translation of the humeral head, and cuff tear arthropathy. Joint-preserving treatment options for IASRCTs in young and high-demand elderly patients remain a subject of ongoing debate. The aim of the study was to evaluate the biomechanical efficacy of the combined latissimus dorsi and teres major tendon (LDTM) transfer and compare it to an isolated latissimus dorsi (LD) transfer in a cadaveric IASRCT model. Eight cadaveric shoulders (mean age, 68.3±5.2 years; range 58-71) were tested with a custom shoulder testing system. All specimens were tested at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane under 4 conditions: (1) intact, (2) IASRCT, (3) combined LDTM transfer, and (4) isolated LD transfer. The superior and anteroinferior translation and subacromial contact pressure were measured. The effects of 3 different LD and LDTM muscle loading conditions were investigated to determine the effectiveness of the muscle transfer conditions. A linear mixed effect model was used for statistical analysis, followed by a Tukey post hoc test. IASRCTs significantly increased superior translation, anteroinferior translation, and subacromial peak contact pressure. Combined LDTM transfer significantly decreased superior and anteroinferior translation compared with IASRCTs in all positions and muscle loadings. Isolated LD transfer did not significantly decrease superior (P>.115) and anteroinferior translation (P>.151) compared to IASRCT at any abduction and muscle loads except superior translation at 60° abduction and 90° of external rotation (ER) (P<.036). LDTM transfer also significantly decreased peak contact pressure from the IASRCT condition at every abduction angle (P<.046). However, isolated LD transfer significantly decreased subacromial peak contact pressure only at 30° abduction and 0° and 30° of ER with triple loading (P<.048), as well as at 60° abduction and 90° of ER (P<.003). Combined LDTM transfer decreased superior translation, anteroinferior translation, and subacromial contact pressure compared with the IASRCT condition. Isolated LD transfer did not improve glenohumeral translation and subacromial contact pressure. Combined LDTM transfer may be a more reliable treatment option than isolated LD transfer in patients with an IASRCT.

Allograft-enhanced latissimus dorsi transfer is better than the conventional technique for irreparable posterosuperior rotator cuff tears. A retrospective matched cohort.

Latissimus dorsi tendon (LDT) transfer (LDTT) to the greater tuberosity to treat irreparable posterosuperior rotator cuff tears (RCTs) in young active patients has been shown to have up to 36% of clinical failures, most of them happening because of either deltoid origin disruption or post-operative transfer rupture from the greater tuberosity. In an attempt to simultaneously prevent both complications, a modified technique includes the following adaptations to the original technique: reinforcement and augmentation of the LDT with a tendinous allograft, enabling the use of a single deltopectoral approach. The aim of this study is to compare mid-term outcomes of the traditional LDTT technique with this modified transfer. Retrospective cohort study comparing two groups who underwent either the traditional (group 1; n = 19) or the modified technique (group 2; n = 27). Group homogenization was assured by statistical comparison of 24 baseline independent variables. The outcome variables were the gains to active shoulder range of motions (ROM) and UCLA scores (and all its subscores, independently), at a minimum follow-up of two years. A p value < .05 was considered to be statistically significant. At a mean follow-up of 25months, both groups have shown improvements to most variables. However, group two (modified technique) achieved greater improvements to UCLA score (p = .009), active external rotation (p = .006) and internal rotation (p = .008). At mid-term follow-up, improvements to outcomes of the modified (single approach, allograft-enhanced) latissimus dorsi transfer were greater than those of the original technique.

Impact of COVID-19 on clinical outcomes following total shoulder arthroplasty

BackgroundThe coronavirus (COVID-19) pandemic has introduced patient stressors and changes to perioperative protocols in total shoulder arthroplasty (TSA). The purpose of this study is to evaluate the short-term effects of the COVID-19 pandemic on various patient outcomes and satisfaction following elective TSA. MethodsA retrospective review was performed on 147 patients who underwent primary TSA at a single institution between June 2019 and December 2020. Patients were divided into 2 cohorts: pre-COVID (June 2019-March 2020; n = 74) and post-COVID (April 2020-December 2020; n = 73). No elective TSA were performed between 10 March 2020 and 23 April 2020 at our institution. Data were collected prospectively both pre- and postoperatively. Range of motion (ROM) testing included active abduction, internal rotation, and external rotation. Patient reported outcome measures (PROMs) included global shoulder function, Simple Shoulder Test, American Shoulder and Elbow Surgeons, Visual Analog Scale pain scoring systems, and patient satisfaction. ROM and PROMs were compared at preoperative, 3-month follow-up, and 12-month follow-up intervals. Operative time, length of stay (LOS), 90-day readmission, and 90-day reoperation were also compared. ResultsThere were no differences in baseline patient characteristics. The operative time, LOS, home discharge rate, readmission, and reoperation did not differ between groups. For both cohorts, the PROMs and ROM improved at each follow-up visit postoperatively. While preoperative abduction, internal rotation, and external rotation were significantly greater in the post-COVID group, all ROM measures were similar at 3-month and 12-month follow-up visits. There was no difference in pain, global function, Simple Shoulder Test, American Shoulder and Elbow Surgeons, or patient satisfaction between groups at all time intervals. ConclusionsPatients undergoing elective TSA amidst the COVID-19 pandemic demonstrate excellent PROMs, ROM, and high satisfaction up to 12-months postoperatively that are comparable to pre-pandemic standards. Operative time, LOS, discharge destination, as well as 90-day readmission and reoperation rates were not impacted by the pandemic. Patients can expect similar outcomes for TSA when comparing pre-COVID to post-COVID as the pandemic continues.

Comparison of reverse shoulder arthroplasty and total shoulder arthroplasty for patients with inflammatory arthritis.

End-stage glenohumeral joint arthritis is common in patients with inflammatory arthritis. Reverse shoulder arthroplasty (RSA) and anatomic total shoulder arthroplasty (TSA) are both indicated in this setting. RSA is often considered based on the impacts of long-standing inflammatory arthritis including glenoid and humeral bone erosion and rotator cuff insufficiency. However, acromial and scapular spine fractures following RSA have been reported more commonly in these patients, which can have a significant impact on outcomes. Currently, no study has directly compared the efficacy and complication rates of RSA vs. TSA in patients with inflammatory arthritis. This study aimed to investigate differences in clinical outcomes and complications in patients undergoing RSA vs. TSA with glenohumeral inflammatory arthritis. We performed a retrospective review of 86 patients with inflammatory arthritis treated with primary RSA (n=43) or TSA (n=43) with a minimum of 2 years' follow-up. American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores, visual analog scale scores for pain and function, active range of motion, and patient self-ratings of upper-extremity normality (Subjective Assessment of Normal Evaluation [SANE]) were collected preoperatively and at minimum 2-year follow-up. Radiographic classification of preoperative glenoid and humeral bone loss was performed, and postoperative complications were observed. Revision and complication details were compared. The study cohort had an average age of 72.1 years (range, 31-92 years) and average follow-up period of 51.6 months (range, 22-159 months). Both the RSA and TSA cohorts demonstrated improvements in patient-reported outcome measures and ranges of motion; however, patients treated with TSA showed a greater postoperative final Simple Shoulder Test score (P<.001), visual analog scale score for function (P=.0347), active elevation (P=.0331), active external rotation (P<.001), active internal rotation (P=.005), and Single Assessment Numeric Evaluation (SANE) score (P=.0161). Analysis of complication rates demonstrated no statistically significant difference between cohorts. Four acromial fractures occurred in the RSA group. When RSA patients who sustainedacromial fractures were removed from the analysis, there were minimal differences in outcomes between the RSA and TSA cohorts. TSA in patients with inflammatory arthritis leads to improved clinical outcomes but higher early revision rates when compared with RSA. RSA outcomes are negatively impacted by a high rate of postoperative acromial fractures.

Ефективність мобілізації та ішемічної компресії при адгезивному капсуліті та міофасціальному больовому синдромі

The purpose of the study was to investigate the effect of end- range mobilization and ischemic compression on the range of motion and pain scores in patients with adhesive capsulitis of the shoulder joint and myofascial pain syndrome in the thoracic spine. Materials and methods. 20 patients participated in the study. Goniometry of the shoulder joint, pain assessment on a numerical scale at the endpoints of the range of motion and trigger points (when applying a pressure of 2.5 kg×cm-2) were performed before the intervention, at the end of the first week of therapy, at the end of the second and third week. Physical therapy began after an examination and consultation with an orthopedic traumatologist. All patients received intensive end-range mobilization performed by a physical therapist and ischemic compression performed by the patient 5 times a week (3 weeks). Mobilization techniques from I to V degrees of intensity according to the Maitland classification system were used. Localization of active and latent trigger points was determined, their marking was carried out on an individual map, which was provided to the patient. The patient was instructed in techniques and methods of influencing trigger points of various locations. Compression was performed with an average or above average pain level and a duration of 30 seconds for each trigger point. Results and discussion. The existence of differences in the results of the amplitude was established, taking into account the time factor. The median score for active abduction increased by 65.5° and for flexion – by 115.5°. The amplitude of active internal rotation increased by 73°, and external – by 72°. According to Friedman's test, similar results were obtained when comparing pain indicators, which were assessed at the endpoints of the range of motion. The dynamics of medians was from 5 to 6 points. The median trigger point pain score decreased by 5.5 points after three weeks of physical therapy. The results obtained when studying the effectiveness of ischemic compression in patients with adhesive capsulitis of the shoulder joint and myofascial pain syndrome are consistent with the conclusions of previous studies and complement the data presented in the literature. Conclusion. Physical therapy, which consists of a combination of end-range mobilization and ischemic compression, is effective in increasing passive and active range of motion in the shoulder joint, reducing pain at the end of the range of motion, and reducing pain at trigger points

Onlay Dynamic Anterior Stabilization With Biceps Transfer for the Treatment of Anterior Glenohumeral Instability Produces Good Clinical Outcomes and Successful Healing at a Minimum 1 Year of Follow-Up

To report the results of the onlay dynamic anterior stabilization (DAS) using the long head of biceps (LHB) and the double double-pulley technique for the treatment of anterior glenohumeral instability (AGI) with ≤20% glenoid bone loss (GBL). From September 2018 to December 2021, patients with AGI and ≤20% GBL were enrolled in a prospective study on DAS and followed for a minimum of 1 year. The primary outcomes were Western Ontario Shoulder Instability Index, Rowe score, range of motion, and strength. The secondary outcomes were ability to return to play (RTP), RTP at same level, lack of recurrence of instability, successful LHB healing, and lack of complications. Magnetic resonance imaging was used to measure GBL, Hill-Sachs interval, glenoid track, and assess LHB integrity. Eighteen consecutive patients underwent DAS. Fifteen patients had a minimum follow-up of 12 months (mean, 23.93 ± 13.67 months). In total, 12 were male and 3 female patients; 73.3% practiced recreational sports; mean age at surgery was 23.40 ± 6.53 years; mean number of dislocation episodes were 10.13 ± 8.42; mean GBL was 8.21 ± 7.39% (range, 0-20.24%); mean Hill-Sachs interval was 15.00 ± 2.96 mm; and mean glenoid track was 18.87 ± 2.57mm. The mean improvement in the Western Ontario Shoulder Instability Index and Rowe score (959.27 ± 386.70 and 74.00 ± 22.22 points) was significant (P < .001 and P < .001) and more than 6 times greater than the minimum clinically important difference. The mean improvement in active elevation, abduction, and external and internal rotation (23.00 ± 27.76°, 33.33 ± 43.78°, 8.33 ± 13.58°, and 0.73 ± 1.28 points) was significant (P= .006, P= .011, P= .032, and P= .044). RTP rate was 93.33%. RTP at same level was 60.00%. One patient with hyperlaxity had a redislocation (6.7% recurrence). No complications were reported. Each magnetic resonance imaging scan showed successful LHB healing to the anterior glenoid. At a minimum of 1-year follow-up, DAS produces significant and clinically important improvements in shoulder function, successful LHB healing, and is safe for the treatment of AGI with ≤20% GBL without severe hyperlaxity. IV, therapeutic case series.

Cut-off values of internal rotation in the glenohumeral joint for functional tasks in children with brachial plexus birth injury.

The aim of this study was to determine the cut-off values of the range of internal rotation motion in the isolated glenohumeral joint that is required for functional tasks in children with an upper root injury of the brachial plexus. Internal rotation motion was measured using a universal goniometer in 97 participants. The Mallet Hand to Spine and Mallet Hand to Belly tasks were assessed as functional tasks that require internal rotation of the shoulder. For the Hand to Spine task, 41° passive and 30° active internal rotation were necessary to reach the S1 level. For the Hand to Belly task, 42° passive and 29° active internal rotation were required to place the palm on the belly without wrist flexion. Of our participants, 97% could touch the belly with or without wrist flexion, but 28% could not reach S1 in the Hand to Spine task. The results of this study show the necessary amount of internal rotation of the shoulder that should be considered in treatment strategies.Level of evidence: III.

Reverse Total Shoulder Arthroplasty with a Cementless and Metaphyseal Stem Fixation Is a Viable Option for the Treatment of Proximal Humeral Fractures with Calcar Involvement.

The purpose of the study was to evaluate the suitability of reverse total shoulder arthroplasty (RTSA) with a cementless and metaphyseal stem fixation as a treatment for complex proximal humeral fractures (PHFs) with a calcar fragment when this may be fixed with a steel wire cerclage. Clinical and radiographic outcomes were compared with the same RTSA for PHFs without a calcar fragment at a minimum of five-year follow-up. A retrospective analysis was performed on acute PHFs "with a medial calcar fragment" (group A) and "without a calcar fragment" (group B) treated with a RTSA and cementless metaphyseal stem fixation. At an average follow-up of 6.7 years (5-7.8 years), no statistical difference was observed comparing group A (18 patients) to group B (50 patients) for active anterior elevation (141 ± 15° vs. 145 ± 10°, p = 0.67), active external rotation ER1 (49 ± 15° vs. 53 ± 13°, p = 0.55), and active internal rotation (5 ± 2 vs. 6 ± 2, p = 0.97). Similarly, a comparison of ASES score (89.2 ± 10 vs. 91.6 ± 9, p = 0.23) and Simple Shoulder Test score (91.1 ± 11 vs. 90.4 ± 10, p = 0.49) revealed no significant difference. RTSA with a cementless and metaphyseal stem fixation represents a safe and feasible treatment for complex PHFs with a medial calcar fragment when this may be fixed with a steel wire cerclage.

Effectiveness of lyophilized growth factors injection for subacromial impingement syndrome: a prospective randomized double-blind placebo-controlled study

BackgroundPlatelet-derived lyophilized growth factors (L-GFs) use a standardized number of allogenic pathogen-free platelets instead of autologous platelets used in PRP as a source of growth factors. This study aimed to evaluate the efficacy of L-GF injection versus placebo in subacromial impingement (SIS) treatment.MethodsThe current randomized double-blind placebo-controlled study included sixty patients (40 females and 20 males, aged between 24 and 75 years) diagnosed with SIS (both clinically and sonographically). Patients were randomly assigned to two equal groups. Under ultrasound guidance, group 1 received subacromial saline injection, and group 2 received L-GF injection. Clinical examination, pain visual analogue scale (VAS), shoulder pain and disability index (SPADI) and shoulder ultrasound were performed before and at the 8th week after injection.ResultsFollow-up assessment showed statistically significant improvement in the L-GF group regarding active flexion, active and passive internal rotation and extension, SPADI-disability scale, VAS and thickness of the supraspinatus tendon by US. Regression analysis showed that group 1 was approximately 30 times more likely than the L-GF group to experience painful arc at follow-up. Both groups showed statistically significant improvement in SPADI-pain scale and SPADI-total, flexion and abduction (still the mean value of abduction was significantly higher in the L-GF group).ConclusionsL-GF injection resulted in clinically significant reductions in pain and functional disability outcomes in patients with SIS. An objective significant reduction in the thickness of the supraspinatus tendon, measured by ultrasound, in the L-GF group hopefully encourages proper healing and functioning in SIS.Trial registration: The identification number is NCT04330027, date of first registration (01/04/2020). Unique on 21/11/2019, Protocol ID: 0106178.

Physiotherapy, Local Acupuncture, and Auricular Acupuncture for Frozen Shoulder

Purpose: To compare local acupuncture and auricular acupuncture with physiotherapy in the treatment of frozen shoulder. Methods: A randomized clinical trial with 3 parallel groups in an outpatient clinic was conducted at a university hospital. In total, 116 participants with frozen shoulder were randomly allocated to 3 groups and underwent physiotherapy or local acupuncture or auricular acupuncture. Shoulder active and passive ranges of motion were assessed, and the Shoulder Pain and Disability Index questionnaire was used to assess pain and disability before and after the treatments. Results: Active and passive ranges of motion were best improved by physiotherapy in abduction and flexion (all P &lt; .001). Passive external rotation was best increased after physiotherapy (P = .030). For active external and internal rotation, and also for passive internal rotation, there were no significant differences among the treatments. Pain reduction was more successful with acupuncture, especially with auricular acupuncture (P &lt; .001). Auricular acupuncture was more effective in improving patients' functional abilities (P &lt; .001). None of the participants reported any side effects resulting from the treatments. Conclusion: Acupuncture, particularly auricular acupuncture, is more effective in relieving pain and decreasing disability than physiotherapy. All the interventions were beneficial in improving range of motion.